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Yes, trainee in York and the Humber on has come to us aspartic her role in gas, which is the green around us. Easier answer. Stain ability. Project on her. Aims within gas to try to help, to try to help to reduce waste, increase recycling and make the chest the green operation, which I think it's something we can. We'll appreciate. So thank you very much, Doctor Lever, for joining us today. And I will get you to share your screen to start presenting high. I'll just start get my slides up, So Okay, Okay. Can everybody see that? Yes. Become perfect. And so hi, everyone. And thank you very much to Julia and Oliver from vitamins to speak at your brilliant sustainability conference. Um, it's been really great hearing about how, with three days is going green and, as you know, has mentioned I am part of gas which is green around. It's easier and sustainability projects. We are multi disciplinary organization that's working towards greening anesthetics, but also the wider theater environment. I have been touched with speaking to you today about the impact of anesthetic gases, but first, I think it is important that we start with just reminding ourselves why this is important. Um, what is that? Steak leaching of cold reefs is one key example of the destructive impact of climate change with increasing global see temperatures. The algae that make the home is either coral are expelled, have temperatures remain high there no able to return to the coral, and it will die this least a loss of habitat and biodiversity and generally disrupts the balance of this ecosystem but also impacts on humans as coral reefs are natural title barriers and they absorb the force of waves. Carbon dioxide levels in the atmosphere in the lifetime have followed this natural ebb and flow. And in the 19 fifties, my parents' generation that we're being told that there would be a nice age and you could forgive them for thinking this because scientists would have been expecting a downturn and I was very excited to as it waas industrialization. Going back to the 18 hundreds clearly was beginning to bite what that CEO to rise equates to. It's an increase in global temperatures. It's hard to appreciate the magnitude of energy required to raise global temperatures, but one example is that to raise the earth's temperature by one degrees Celsius. This requires the equivalent energy consumption of the USA for four million years. Carbon dioxide levels in the atmosphere just this week are at 420.58 parts per million, which is up by 1.1 parts per million. Since last year. The results have rising. So two and rising temperatures is what we're seeing in the news on a daily weekly monthly basis. Extreme weather, floods, famine, wildfires, drought, record high temperatures in Antarctica. I could go on, but we can't go on like this and the Earth is victory on fire. Healthcare Without Home is a global organization that's working to tackle the impact of healthcare on the environment that they calculated that if healthcare was a country, it would be the fifth largest admitted of 02 in the world. In the UK, the attic chest contribute to 5% of our national oh two emissions, so we've really got work to do. So how are we going to change? Professor Booster has already showed me the spy chart, but I think it's worth briefly revisiting if you'll give me the time. The NHS is broken down. It's carbon footprint by contributors, so this spits them up into those outside. The NHS is direct control, which you're on blue on those that those within our direct control, which would agree so factors outside our direct control of things like pharmaceuticals, medical equipment, supplies, chain on factors within our control are things like water and waste staff commuting, building energy. But also included on the left is anesthetic gases and metered dose inhalers. On this is where is an East it's We can make a significant contribution to reducing or carbon footprint. Okay, this is another graph produced by the NHS, which shows the 02 emissions the historic emissions of seeing at the top left, and you can see that they were coming down. However, a few years ago, we hit a crossroads and you can see projections of emissions if we were to take no action, which is the dash line of the top and projections of emissions. If we tackled all the areas listed in the dash line, going down toward zero, the blue section in particular, holds relevance for any cysts, GPS and anybody who's using nitrous or intern ox on the blue which could be wiped out if we make the change is required to green if I anesthetics and stop prescribing me to dose inhalers in particular, I couldn't do this talk. I do apologize. I couldn't do it without plugging my own trust, who have been incredibly engaged with doing their bit to tackle the climate crisis. What's the NHS is a whole has pledged to be next year by 2045. My trust has been a lot more ambitious and is only to be nosy about 2030 on They are well on their way. They've built their own solar form, which the other week was featured on the BBC as one of our main hospitals was entirely powered by the solar form for a whole day. They were making so much energy they actually sold it back to the grid. In addition, we've already reduced anesthetic gases emissions by over 50% through reduction of desflurane and nitrous oxide. There is still what to do, but it is great seeing trust that is so motivated. So the science bit basic science. I'm not a viral mental scientist, but anesthetic gases are greenhouse gases. Once released into the atmosphere they essentially add to this carpet of gas is in the stratosphere and drops for usually so no energy travels from the sun, reaches the earth and is reflected back out into space. But greenhouse gases trump the energy and prevent it from escaping backing space, which warms up on it. So our three main Aricept volatile agents are in this yellow box desflurane, isoflurane and CVA for it. But you could also see nitrous in blue CO2 me thrown a water vapor city in the same part of the atmosphere, all of which are acting as greenhouse gases. So how do we decide the badness of the greenhouse gas? We use a measurement called global warming potential. Good Woman potential is made up of two factors, firstly, the atmospheric lifetime of gas, and secondly, it's ability to absorb infrared radiation. It's a measure of how many times more powerful gases that heat trapping compared to the same mass for reference gas, which is usually calm dioxide when we measure this over 100 years. This enables a direct comparison of greenhouse gases, so you could see here that CO2 has a global warming potential of one because it's the reference gas, and it hangs around in the atmosphere for up to 1000 years me today and has a great warming potential up to 36 times higher than 02. A nitrous oxide is 265 times out of the 02, which means whatever nitrous we're releasing into the atmosphere today is still going to be on the Earth when our grandchildren and great grandchildren are born. The bottom category includes anesthetic gases, So let's look at the numbers. You can see here that the obvious outlier is does for reading, which is the blue canister that you can see on the left. It has a global me potential of 2540 times that, too. It is a guess we are moving away from an anesthetic. Thankfully, is it doesn't really have any clinical advantage of receiver flurry on It's anesthetic Impact, as professor but it's mentioned is absolutely horrendous. And it is important, though, to talk about nitrous while swallowtail anesthetic, so receiver for a rain. I suffer in a desperate do. You have very high global warming potentials, and they are definitely a problem. They actually contribute less than a quarter of the anesthetic gas. Cop of Footprint, where it's nitrous, contributes over three quarters of the anesthetic gas. Carbon footprint, freely situs. There's an easy way to assess the environmental impact of of a little anesthetics. The anesthetic impact calculator App was produced by Dr Tom Pierce. Here is the colleges environmental Advisor. It allows you to improve your anesthetic figures into a sort of mini anesthetic machine. On It will tell you both how expensive your anesthetic is, which is relevant, particular desflurane because it's very expensive and also the environmental impact in equivalent distance driving for patients. There is an excellent resource on the colleges website called Your Anesthetic and the Environment on this Aerospatiale's to see Clearly what the impact of our gas is is. It's clear that obviously patient safety and comfort is of paramount importance, and sometimes clinical care will have to override any environmental concerns. But wherever possible, we should be considering both the patient on the environmental impact as one. So I've talked a lot about the problem. But what are the solutions so firstly, don't give a general anesthetic use regional instead that could be a spinal or a nerve block, and this is something I'm sure you're familiar with. The North Pedic. Send something that we should be promoting as much as possible. Regional anesthesia has a much more environmentally friendly profile, and it's also beneficial for the patient as they don't have the risks of a general anesthetic. Sometimes, of course, it's not appropriate option. That is what we should be trying to lean towards wherever possible. Secondly, if you're going to give a general anesthetic than do differently, so one option here is to use total intravenous on this easier or TBA. This involves running a syringe of propofol on an opiate throughout the operation to keep the patient anesthetized. We turn it off about five minutes before the end of the operation, and the patients generally wake up really, really nicely. It also acts as an antiemetics, so it's doubly good. In my book. I actually really like using TV just because the wake up is really good. But people do get concerned understandably about the plastic, the pumps, the electricity and the propofol. And this is a reasonable concern, especially is propofol is made from soybean oil on We have quite limited information available regarding the sources of the soybean oil for pro for Shin, however, in life cycle and else's when compared with a volatile anesthetic. So your standard gas anesthetic, the greenhouse gas impacts of TV of four orders of magnitude lower. So the moment it's the more environmentally friendly option. If, after a while that you still want to use a gas for your anesthetic, then captured technology is starting to be adopted. So it's a check is a British company on Baxter's, a German company, and they both make canisters, which absorb the volatile gas through the scavenging system that comes out of the anesthetic machine and connects to the wall. This is the canisters the transported to the companies home facility and that gas is a kind of distilled out of the canister and could be separated ideally in the future that be able to recycle scavenge gas is creating a sort of closed economy on that would stop was really seeing these gases into the atmosphere. I am sure this is a familiar sight, too many of you, a classic emergency department phone call to ask you to come and help reduce the desiccated shoulder on your patient is uncomfortable, and you need to get in some decent pain relief. And I've already told you about the problems with nitrous. So what are you going to use instead? So first choice conscious sedation you could use either propofol, catamenia or bit of both, and this is a really good option that should get your potion nice and relaxed of floppy enough to give you the better chance of success of getting that shoulder back in. However, this option has that caveat of needing either an E D Register or a consultant who's confident in sedation to give you a hand in the current time of e. D. I don't know how realistic it is to be able to pull someone away from the shop floor for this, but if they're able to, then it's a really good option. Again, it's important to remember that no all emergency departments will have doctors who are competent in this technique, especially at nighttime. And it's important that we the sedatives are only used by those who are competent to do so on booking us one team with our emergency department colleagues as well. So if you can't do that. This is another option. So pen frocks, which is known in the prehospital world, particularly down under as the green whistle on this is an anesthetic volatile agent as well, just like CEO High. So it does. But it's methoxyflurane, which has been made into a powder. It's tipped into this plastic whistle on the patient, inhales and exhale through the whistle. On they become particular, but they get really decent relief on. It's a good option for patients, particularly when there's no be able to deliver contrast a shin or if the patient maybe has difficult IV access. I have given this to a number of patients and needy to age with fracture, with inflation on dislocations, and it generally goes down really well. If, however, the patient doesn't exhale, probably back through the inhaler, you will probably get a with of it. So we were because it might make you a little bit giddy. Also, um, pen trucks has a global warming potential of four, so it is significantly better than the 265 that you get with nitrous. But like all of these things, it does have a disposal problem in that it's single use plastic, and I'm not convinced it's recyclable. So what next? If you really want to use interlocks, there is new technology coming through to help reduce his environmental impact. So Medicare is a Scandinavian company that's created a scavenging and cracking system for and knocks essentially instead of just having one and spiritually homes from the cylinder or the wall to the mouthpiece. It also has an expert, Rijo is, which plugs into this machine that you can see on the left. The patient needs to keep the mouthpiece in their mouth. For expiration is, well, much like the pens rocks on. This means that the expired gases will go into the experience, the hose and into the machine. The machine is quite a basic but of technology in the sense that it just heats up the gas to 400 degrees Celsius on that splits the nitrous into nitrogen on oxygen, which could be released harmlessly into the atmosphere. These machines, all relatively new to the UK and they're expensive. The picture here shows you a mobile unit. But Medicare also make a system that can kind of be plumbed into the nitrous manifold system as well. It's going to take time for the UK to adopt this kind of technology, and realistically, it's gonna be maternity unit to get it first because they have the host use event knocks. However, I would expect and hope that the emergency department will be next. So essentially, really watch this space. So thanks very much for listening. That's all I have to say. Really. I hope it's been helpful. If anyone has questions, I think that's a Q and A session, so I can try and help on. If anybody would like to join. Gasp, let me know, because it's not just for any statistics. We've got lots of other specialties, including pediatricians GP psychiatrists often gynie emergency medicine, just one big happy family. So if anyone would like to join, please get in touch Theorem. Assist is here. But if you want these, I can send them to Julia and chicken for that on to you, as that's everything for me. Thanks very much for this thing